International Survey: U.S. Leads in Medical Errors

U.S. Has Highest Out-of-Pocket Expenses and Rates of Foregone Care Due to Costs

New York City, November 3, 2005—One-third of patients with health problems in the U.S. report experiencing medical, medication, or test errors, the highest rate of any nation in a new Commonwealth Fund international survey. Assessing health care access, safety, and care coordination in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States, the survey found that while no one nation was best or worst overall, the U.S. stood out for high error rates, inefficient coordination of care, and high out-of-pocket costs leading to barriers to access to care.

"While the consistently high error rates and lack of coordination are disturbing, the findings also highlight the potential for each country to improve," said Fund President Karen Davis. "Some countries have been able to achieve timely access to needed care while reducing financial barriers. Each country could also gain through strategies to improve the quality and efficiency of care, such as implementing modern information technology systems, supporting patient engagement in care, and improving management of chronic conditions."

The 2005 survey of adults with health problems is the eighth in an annual series of cross-national surveys conducted by Harris Interactive for the Fund.

One–third (34%) of U.S. survey participants reported at least one of four types of errors: they believed they experienced a medical mistake in treatment or care, were given the wrong medication or dose, given incorrect results for a test, or experienced delays in being notified about abnormal test results. Three of ten (30%) Canadian respondents reported at least one of these errors, as did one-fifth or more of patients in Australia (27%), New Zealand (25%), Germany (23%) and the United Kingdom (22%).

U.S. patients who saw four or more doctors in the past two years were especially vulnerable, with about half (48%) reporting at least one of these errors, pointing to lapses in communication during transitions.

Although attention to patient safety has focused chiefly on care in hospitals, a majority of patients (60% or more) in each country who reported medical mistakes or medical errors said these errors occurred outside the hospital, highlighting the need for policies to improve patient safety in ambulatory care.

"There were many symptoms of poorly coordinated care in every country, regardless of the type of delivery or financing system," said Schoen. "Shortfalls were particularly evident for people when discharged from the hospital, and for patients seeing multiple physicians. Improved care coordination during transitions across sites of care and providers offer opportunities for significant improvement. These patients are the 'canary in the coal mine' of any health system."

In all six countries, one-third or more of recently hospitalized patients reported failures to coordinate care during hospital discharge. Germany had the highest rate of patients reporting lack of follow-up care, with three–fifths (60%) saying the hospital did not make arrangements for follow-up visits with a doctor or other health professional or otherwise give instructions about post hospital care, such as symptoms to watch for and when to seek further care.

The U.S. had the highest rate of patients reporting coordination of care problems that reflected inefficient care during doctor visits. One–third (33%) of U.S. respondents said that within the past two years, either their test results or records were not available at the time of a doctor's appointment, or that a doctor had ordered a test that had already been done. Rates of care coordination problems in the U.S. were significantly higher than those in the other five countries, which ranged between about one–fifth to one–quarter reporting coordination problems.

Patients with chronic diseases in all of the countries often did not receive the care recommended to manage their condition. At best, about half of diabetics reported receiving all of the four recommended screening exams to manage their condition. Patients who had supports such as a self management plan or a nurse included as part of their care management team were significantly more likely to have received recommended care.

The U.S. was an outlier for its financial burdens on patients:

Half (51%) of the U.S. adults reported they had gone without care because of costs in the past year.

In contrast, just thirteen percent of U.K. adults reported not getting needed care because of cost.

One–third (34%) of U.S. patients reported out-of-pocket expenses over $1,000 in the past year.

U.K. patients were the most protected from high cost burdens, with two-thirds (65%) having no out-of-pocket expenses. The variations were notable given the study design focus on sicker adults with recent intensive use of medical care.

Access—including after-hours access—and waiting times to see a doctor when sick differed markedly across the countries:

Canadian and U.S. adults who needed medical care were the least likely to report fast access (same day) to doctors (30% or less of U.S. or Canadian patients).

In contrast, majorities of patients in New Zealand (58%) and Germany (56%) reported they were able to get same-day appointments, as did nearly half of patients in Australia (49%) and the U.K. (45%).

Majorities of patients in Germany (72%), New Zealand (70%), and the U.K. (57%) also reported that after-hours (nights, weekends, or holidays) access to a doctor was easy.

In contrast, majorities of patients in the U.S. (60%), Australia (58%), and Canada (53%) said it was very or somewhat difficult to get after-hours care.

The four countries with comparatively more rapid access to physicians—Australia, Germany, New Zealand, and the U.K.—also had significantly lower rates of emergency room use, with Germany having the lowest rates.

One–fifth of Canadians and one–fourth of U.S. patients who reported going to the ER said it was for a condition that could have been treated by their regular doctor if available.

The findings highlight the need for improved access as well as coordination of care. The authors conclude that "These findings suggest that many of the problems with which policy leaders are grappling transcend specific payment or delivery systems and will require more fundamental transformation."

Methodology: The survey screened initial random samples of adults age eighteen or older to identify those who met at least one of four criteria: rated their health as fair or poor; reported that they had a serious illness, injury, or disability that required intense medical care in the past two years; or reported that in the past two years they had major surgery or had been hospitalized for something other than a normal pregnancy. The final study includes 700-750 adults in Australia, Canada and New Zealand and 1,500 or more in the U.K., U.S. and Germany. The Commonwealth Fund funded the core study and partnered with the Health Foundation to expand the United Kingdom sample. The German Institute for Quality and Economic Efficiency in Health Care funded the German sample. The questionnaire was designed by researchers at The Commonwealth Fund and Harris Interactive, with advice of experts in each country. Interviews were conducted by telephone between March 17 and May 9, 2005 in the five English speaking countries and May 9 to June 12, 2005 in Germany. The survey was conducted in German in Germany and English in the five other countries, with an option for French in Canada and Spanish in the United States. The margin of sample error for country averages are approximately: +/- 4% for Australia, Canada and New Zealand, +/- 3% Germany and U.S., and +/-2% for U.K. at the 95 percent confidence level.

Mission

The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.